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Dermatopathology: Practical & Conceptual January - March 2003
Contrary View on Behalf of Patients: Sentinel lymph node biopsy has no benefit for patients with primary cutaneous melanoma: An assertion based on comprehensive, critical analysis.
Neil Medalie, M.D.
A. Bernard Ackerman, M.D.
1. Elective Lymph Node Dissection: Historical Perspective
2. Diagnosis of Metastasis of Melanoma in Sentinel Nodes: Past and Present.
3. Evolution of Methods for Mapping Lymph Nodes: From Determination of a Regional Node Basin to Detection of a Sentinel Node.
4. Sentinel Node Biopsy: Standard of Care?
5. Concepts regarding the mechanisms of dissemination of melanoma
6. Metastatic Melanoma: No systemic therapy currently available is effective.
7. A Last Word – Sentinel node biopsy provides no benefit to patients and, therefore, should be abandoned now
sentinel lymph node biopsy
A primary cutaneous melanoma* that has not yet metastasized is curable by excision
no additional treatment is required. Once metastasis of melanoma becomes apparent clinically, it is likely that if the patient lives long enough and does not die of something else, death, in time, will occur from the effects of metastases. Whether that will happen in months or decades, cannot be determined. A patient may have a metastasis of melanoma that is not evident clinically or by any kind of examination available currently and that person's destiny also is sealed. Nowadays, a patient presumed to have a metastasis of melanoma is given three options: 1) elective lymph node dissection (END),** an operation that was introduced in the nineteenth century, 2) adjuvant medical therapy, the one most in vogue currently being interferon, and 3) sentinel lymph node biopsy (SNB), a procedure proposed at the end of the twentieth century for the purpose of diagnosing a metastasis of melanoma in a node when no node is palpable clinically.
These three modalities have been studied and written about extensively; all three remain controversial and, as a consequence, the legitimacy of them is debatable. This endeavor by us was undertaken in order to assess critically each of the three modalities. We sought to accomplish the desideration by reviewing incisively the important medical literature that pertains to each of them, by elucidating major matters of controversy in regard to END, adjuvant medical therapy, and SNB, and by analyzing each of the issues in a logical, insightful, unbiased manner. The objective, in short, is to make these subjects readily comprehensible and, by virtue of that, to lead a reader, in Socratic fashion, to conclusions that are compelling because the evidence for them is so powerfully incontrovertible. If that goal is achieved, as we are confident it will be, then patients will be beneficiaries ultimately. That is our
and what follows is animated by the mentality and the spirit just enunciated.
* In the remainder of this work, the word "melanoma," unqualified or unmodified, will mean "primary cutaneous melanoma."
** Throughout the rest of this work, the term "node" will stand for "lymph node."
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